Robot-assisted laparoscopic partial nephrectomy with renal artery clamping using an endovascular balloon catheter for an allograft kidney tumor: A new perspective to manage renal vascular control?

Abstract

To the Editor: This report focuses on the first robot-assisted laparoscopic partial nephrectomy (RAPN) with endovascular control of the renal artery using a balloon catheter for an allograft kidney tumor. The patient was a 48-year-old male who underwent right iliac fossa transplantation in 2003 for end-stage renal disease. In July 2017, a screening abdominal ultrasound scan highlighted a 2-cm complex cystic renal mass (Bosniak 4) on the upper pole of the transplanted kidney and a simple cyst next to the first tumor. Magnetic resonance imaging confirmed the suspicious lesion shown on the ultrasound scan (Figure 1A). Preoperative serum creatinine was 128 μmol/L with an eGFR of 57 mL/min per 1.73 m2 (Chronic Kidney Disease-Epidemiology Collaboration Equation). First, to avoid renal allograft pedicle dissection with its known complications, we selected a radiological endovascular technique under local anesthesia (Figure 1B). An Armada 35 LL PTA balloon catheter, 6 mm in diameter and 200 mm long (Abbott Vascular, Green Oaks, IL) was used in order to occlude the renal artery during tumor excision. A balloon catheter was placed in the kidney transplant artery. Complete occlusion was obtained with a balloon pressure of 6 atmospheres. The procedure took 12 minutes. Secondly, the patient was transferred to the operating theater where surgery was performed with the patient under general anesthesia. We used a 4-arm Si HD da Vinci robot (Intuitive Surgical Inc., Sunnyvale, CA) with standard port placement (Figure 1C). The following procedural steps were performed sequentially: transperitoneal dissection of the common iliac artery to provide proximal vascular control in the case of incomplete renal artery occlusion, a tumor per-operative ultrasonographic location, endovascular control of the renal artery, monobloc excision (Figure 1D), early unclamping and suture of the parenchyma, renorrhaphy using a sliding weck clip technique, and tumor extraction. Surgery took 60 minutes with a warm ischemia time of 8.2 minutes. Estimated blood loss was <50 mL. No per- or postoperative complications occurred. Immediate postoperative Doppler ultrasound of the kidney vessels was normal. The arterial catheter was removed immediately after surgery. The patient was discharged 2 days postoperatively. Postoperative serum creatinine levels were 135 μmol/L with an eGFR of 53 mL/min per 1.73 m2 (Chronic Kidney Disease-Epidemiology Collaboration Equation). Histopathology revealed a cystic tumor with low-grade renal cell carcinoma. Surgical margins were negative. Partial nephrectomy is considered the reference treatment in localized renal tumors of <7 cm (cT1).1Ljungberg B Bensalah K Canfield S et al.EAU guidelines on renal cell carcinoma: 2014 update.Eur Urol. 2015; 67 (https://doi.org/10.1016/j.eururo.2015.01.005.): 913-924Abstract Full Text Full Text PDF PubMed Scopus (1783) Google Scholar The literature on nephron-sparing surgery in renal allografts is sparse and limited to patients with small masses.2Chambade D Meria P Tariel E et al.Nephron sparing surgery is a feasible and efficient treatment of T1a renal cell carcinoma in kidney transplant: a prospective series from a single center.J Urol. 2008; 180 (https://doi.org/10.1016/j.juro.2008.07.055.): 2106-2109Crossref PubMed Scopus (0) Google Scholar In most cases, the reports describe open partial nephrectomy.3Vasisth G Kapoor A Piercey K Lambe S Renal cell carcinoma in renal allograft: case series and review of literature.Urol Ann. 2018; 10 (https://doi.org/10.4103/ua.ua_66_17.): 229-232Crossref PubMed Google Scholar RAPN on kidney transplantation was initially described by Kaouk et al and was presented as a safe and effective procedure.4Kaouk JH Spana G Hillyer SP White MA Haber G-P Goldfarb D Robotic-assisted laparoscopic partial nephrectomy for a 7-cm mass in a renal allograft.Am J Transplant. 2011; 11 (https://doi.org/10.1111/j.1600-6143.2011.03655.x.): 2242-2246Crossref PubMed Scopus (0) Google Scholar Cl